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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR FROM DATE ISSUED I (Complete in Triplicate) t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weVpump and the Rules and Regulations of the San Joaquin Local Health District. I � r CJ Job Address qlo 72,F. City" Lot Size PM Owner's Name Address 79 F, Phone k Contract r ,�_'& Addresser_ 767 .4f License Nc>tjrt12ZCe Phone S109-.5,10-5, TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j t O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing Cl Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications , 'I 1-1 Public D Other F I Delta .Depth of Grout-Seal Type of Grout I I Irrigation - -Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump`` '.w r H.P. t J ,_State Work Done_ ` Well Destruction ❑ Well Diameter Sealing Material (top 50') 6 Depth Material {Below 50'1 TYPE OF SEPTIC-WORK: NEW INSTAL ATION [_1 EPAIR ADDITION ,DESTRUCTION [ I (No septic system permitted if public sewer is yF X_.".,_,«'-) . , ,f , -t ✓ �, available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedroon)s r Charactef of soil to a depth of 3 feet:I s ' _ _ _ Water table depth SEPTIC TANK ❑ Type/Mfg 47 ' Capacity ` No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -—.Foundation : Property Line O LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well FoundationProperty Line SEEPAGE PITS Depth Size _ Number SUMPS L-1Distance to nearest: Well t�QJ Foundation 40 `'Property Line L.�,_--_ DISPOSAL PONDS ❑ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that-in_the.performance-of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ-persons subject to workman's compensa- tion laws of California." W� The applicantt call for I re ired inspections. Complete drawing on reverse si i t Signed X Title: ` J ..Date: V } FOR DEPARTMENT USE ONLY G J t Application Accepted by Date_ � �/ �✓ 'S'4rea / Z ��"' 1''s Pit or Grout Inspection by 1 t Final Inspection by Date,�� [L Additional Comments: [[ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # .. iFEEO AMOUNT DUE,yt I AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. +.EH13-241REV.i/85i a ^ EH 14-28 Ll --ILS2 q0 -1